Integrated Care Plan for Health Care Quality and Access
Trial Summary
What is the purpose of this trial?
The Integrated Care Pathway (ICP) model can reduce hospital readmissions and emergency department (ED) visits while improving continuity of care. This model was first developed at the University Health Network in Toronto, Ontario, and has been adapted for patients at high risk of readmission and with medical/social vulnerability admitted to general medical units in the hospitals in Calgary, Alberta. The study will evaluate the ongoing adaption and implementation of the ICP model in Calgary. ICP patients will receive the following tenets of care: 1. Continuity of care - After determining the patient's inventory of needs, study participants will then be assigned to an ICP team member who will follow them throughout their hospitalization to support their discharge planning and to advocate for their needs in hospital. 2. Intensive Case Management - The ICL will liaise with hospital, primary care and community partners to develop a tailored complex care plan to support the patient's transition home. This will be documented in the hospital's electronic medical record (EMR) and incorporated into the discharge summary at the time of hospital discharge. 3. Post-discharge support * 24 hour access to phone support within the first 2 weeks of discharge from hospital, leveraging the ICP, community stakeholders and Healthlink from Alberta Health Services. * Long-term support and follow-up in the community up to 90 days with goal of implementing and adapting the complex care plan to help patients access services and manage their chronic health conditions. The main study objectives are: 1. To adapt and implement the ICP in Calgary's 4 hospitals over a 3 year period. 2. To evaluate the implementation of the ICP in Calgary leveraging the Quintuple Aim Framework. Methods: Patients enrolled in ICP will be compared with comparator patients in control sites to evaluate the model's effectiveness. Since the ICP is new to Calgary, the research team will be evaluating how well it performs compared to usual transitions in care by collecting data to learn about: 1. How patients and their caregivers experienced their time in hospital and transition home. 2. How healthcare providers feel about the ICP's impact on patient care. 3. The ICP's impact on patient health outcomes, 4. The use of hospital resources, and the cost of providing care. 5. The ICP's impact on equity, or fair access to healthcare resources and services.
Do I need to stop my current medications for this trial?
The trial information does not specify whether you need to stop taking your current medications. It seems focused on care coordination rather than medication changes, so you may not need to stop them, but it's best to confirm with the trial coordinators.
What data supports the effectiveness of the treatment Integrated care plan?
Integrated care plans, which aim to improve coordination and continuity of care, have shown modest benefits for patients with complex or chronic illnesses, although evidence is sometimes conflicting. They are believed to enhance patient experiences and outcomes, especially when care is personalized and goal-oriented.12345
Is the Integrated Care Plan generally safe for humans?
The research articles focus on adverse events in healthcare settings, highlighting the importance of improving patient safety and preventing adverse events through better integration, communication, and education. However, they do not provide specific safety data for the Integrated Care Plan itself.678910
How is the integrated care plan treatment different from other treatments?
Research Team
Michelle Grinman, MD FRCPC MPH
Principal Investigator
University of Calgary
Eligibility Criteria
This trial is for patients at high risk of hospital readmission and with medical or social vulnerabilities admitted to general medical units in Calgary hospitals. It aims to improve care quality and access, focusing on those who might benefit from an integrated care plan.Inclusion Criteria
Exclusion Criteria
Timeline
Screening
Participants are screened for eligibility to participate in the trial
Hospitalization and Discharge Planning
Participants are assigned to an ICP team member who supports discharge planning and advocates for their needs during hospitalization.
Post-discharge Support
Participants receive 24-hour phone support for the first 2 weeks post-discharge and long-term support up to 90 days to implement and adapt the complex care plan.
Follow-up
Participants are monitored for safety and effectiveness after discharge, with follow-up visits to primary care and subspecialty care.
Treatment Details
Interventions
- Integrated care plan
Find a Clinic Near You
Who Is Running the Clinical Trial?
University of Calgary
Lead Sponsor
Canadian Institutes of Health Research (CIHR)
Collaborator